No Patient Left Behind

The Problem

Canada ranks near the bottom among high-income countries for timely access to primary care, specialist care, hospital services, community care, and elective surgery. These access gaps create bottlenecks throughout the system, driving patients to emergency departments (EDs), which function as the system's universal contingency plan and only open door. As a result, Canada has the highest ED utilization rate of all high-income countries.

When patients receive care in the wrong setting or experience prolonged delays, outcomes worsen. Frail older adults awaiting community care often remain in acute-care hospital beds for weeks, causing cognitive decline, deconditioning and subsequent institutionalization. These “ALC patients” limit hospital capacity and delay inflow from the ED. Admitted patients waiting for inpatient ward beds are held, often for days, in noisy ED stretchers with suboptimal care, poor sleep and limited bathroom access, factors that drive prolonged hospital lengths of stay. Inpatients accumulate in ED stretchers and prevent ED inflow, forcing seriously ill arrivals to waiting areas where they face long waits, untreated pain, clinical deterioration and, too often, disastrous outcomes.

The Causes

Canada faces real capacity challenges, including physician shortages, a relative paucity of hospital beds, and an aging population with increasing healthcare needs, but capacity is not the only concern. A fundamental issue is the lack of program accountability for patient access and system flow. While providers have a general understanding that they should try to reduce care delays, there is no expectation they will do so, nor consequences for failure. In the face of rising demand and growing care delays, programs might choose to initiate difficult system innovation but, in our system, it is also acceptable to continue usual processes and restrict access when it seems necessary. Management by closing doors delivers huge rewards: workload is controlled, waiting patients out of sight and out of mind, staff stress relieved, and budgetary challenges mitigated. Care shortfalls become someone else's problem and programs are protected from evolutionary stressors that would otherwise mandate change and innovation.

The Solutions

This is system failure, not provider failure, and we have two main recommendations: operational improvement and accountability frameworks. Operations researchers suggest that process optimization can increase flow and throughput by 30 to 50 percent. A large Canadian ED study found that even small 2 to 4 percent hospital flow enhancements would enable EDs to rapidly manage all high acuity patients and eliminate waiting room deteriorations. Innovation and process improvement will not assure the right care in the right place for all patients, but they will reduce wait times and eliminate most emergency access blocks.

Accountability frameworks are critical but oddly rare in healthcare. They specify accountability zones (which program is most responsible for which patients) and they define program expectations, including timely care access and the need for effective queue management and surge strategies. Without defined accountability zones and care expectations, an acceptable program response to care gaps is, “Sorry, we are full” (join the queue). In an accountable system, program leaders would instead ask, “How can we change our systems if closing the door is not an option?”

Doctors, nurses and health leaders are almost invariably good people who want the best for their patients, and most agree with accountability as a concept. Unfortunately, they often believe accountability is impossible because of resource limitations, too many ALC patients, or too many boarding inpatients. They often protest that they are already doing everything possible, and that you cannot just push more patients into a full system.

Questions for Program Leaders

Facing these perceived barriers, it is worth asking program leaders about:

• Strategic planning: Is your team aware of your accountability zone (your queuing patients)?
• Innovation: Ask your teams, How would you change if closing the door was not an option?
• Utilization: Yes you are full, but do all the patients need a hospital bed or ED stretcher?
• Rationing: Are you prioritizing patients with greatest need, or are some of the sickest outside?
• Operations and flow: Are you smoothing, fixing bottlenecks, admitting and discharging seven days a week?
• Do you have non-value added processes, redundant care, avoidable testing, consult delays?
• Are you matching demand to capacity and reducing variability?
• Do you have a demand-driven overcapacity plan?
• Could you explore new staffing models and expanded scopes to increase care capacity?
• Have you fixed bottlenecks and unloaded bottleneck providers?
• Are you triaging and reverse triaging to assure ethical allocation?
• Do you have goals or targets for flow and access?

Very few programs have exploited all available improvement opportunities, and substantial optimization is possible. No Patient Left Behind can make a difference by promoting and supporting operational innovation, by developing effective leaders, and by driving policy change that leads to a more accountable system using accountability frameworks and strategies.